By Tim Petito, OD, FAAO
Jan. 16, 2018
Patients say they want telehealth-enabled access to their doctors, and many doctors find greater convenience and ability to provide care through telehealth, but how do we do it so patients are not harmed?
What is Telehealth?
I define telehealth as synchronous (real-time) access to voice with data and /or images conveying patient information and/or medical data to accomplish a medical goal. Phone calls do not count, and asynchronous processes, like store-and-forward photographic approaches does not count. Store-and-forward used to be called “mail me a picture,” and it still is, except now the mail is e-mail rather than postal mail.
The definition of telehealth keeps expanding to include everything from phone calls to people accessing their health portal. I don’t think doing the same old things, like looking at your historical record (which used to be on paper in a file) is a huge leap forward just because it is online. I would like to see this “new frontier” in medicine refer just to advanced technologies and procedures that advance care, rather than the same old processes in a new format.
2018 Telehealth Symposium Recap
>>CLICK HERE>> for an account of the program, which was sponsored by Essilor.
If Telehealth Doesn’t Improve Care, Don’t Do It
My office communicates with patients through telephone, e-mail, compliant text and portals, but that is not really what I consider telehealth. We don’t utilize synchronous remote capture of exam data in my office, partly because the technology for synchronous remote capture does not improve the level of care we can provide, partially because there is not a compelling medical reason for remote data capture where I practice, and because I gather a lot of information from the face-to-face interaction with my patients that I can’t get through video interactions or a phone call.
However, I do consult with other practitioners in real time utilizing medical data and images, which is a form of telemedicine that can improve point-of-care decision making, and therefore, enhance care.
We can either video-chat with our secondary, or tertiary-level, referral providers, or send them images which we discuss via telephone or computer voice channels to decide on a plan of action to initiate with the patient. We are not yet having the patient see the referral doctor directly via video from our office, but I don’t see why that wouldn’t be the next logical step, in those cases where that interaction would be helpful.
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Telehealth Is Not for First-Time Patients
I believe telemedicine should provide the same, or better, quality of care as face-to-face (current or traditional) methodologies. Proponents can point to evidence that a test can be done as well, or better, through telemedicine than through face-to-face care, but studies like that ignore the totality of outcomes.
This “evidence” is for fragmented care, which we all know (and mountains of evidence prove) is not the best approach and is much more expensive in the long-run. One of the six national health priorities is increasing care coordination, but fragmenting care and relying on individual tests in a screening-only approach to care is the opposite of this priority.
Telemedicine should not be the first encounter for new patients to establish the primary doctor-patient relationship. Telemedicine-based processes and procedures should be prescribed as any other testing or referral protocol is, and informed consent for the use of telemedicine, listing the potential risks and benefits of this methodology, should be given to the patient with a choice to accept or reject it.
AI Could Take Care to Next Level–If Used Judiciously
Artificial intelligence is a potentially a huge improvement in two aspects of providing care.
First, it can analyze massive amounts of data in terms of literature, which allows us to utilize a more complete knowledge base in diagnosing conditions and formulating treatment plans.
Second, it can analyze clinical data in ways that are not possible without it; either because the volume of data is too great, or the analysis is too complex. For example, calculating the total volume of retinal edema from OCT data.
However, knowing the most likely diagnosis, and the treatment that has the best chance of success, is not necessarily the hardest or most impactful part of providing care. Explaining the condition, potential treatment options (and why one is the best), and the consequences of all those options to the patient, to their significant others and caregivers in an empathetic, understandable way, is the essence of good medicine, and incredibly important to compliance and successful outcomes.
Dig Deeper Into Telehealth
Those explanations and the history which begins each encounter have to be customized for the intellectual, social, cultural and psychological condition of each patient, who is often highly stressed. That is the analog process which cannot be provided through artificial intelligence, or any other technology.
Many proponents of telemedicine and the technologies that enable it want to replace doctor-provided comprehensive care with automated fragmented testing machine-based analysis, which cannot improve care without the human interaction that starts and finishes each encounter and episode of care.
If You Do Telehealth, Be Mindful of HIPAA Patient Protections
We have just upgraded our computer systems to improve our security, and we utilize HIPAA-compliant platforms for communication. But I also will be investing in a HIPAA-compliance consultant, because this issue has become too complex to manage in a small private practice without dedicated and knowledgeable staff. So, in a few months we may be doing everything differently than we do now.
Set Boundaries with Patients
We have all had patients (often family or friends) who will send the odd selfie or texted description of a problem they are having, and I would not be honest if I said I have never used that information to make a tentative diagnosis and initiated treatment from that encounter.
However, I always give them informed consent, describing the potential problems with care through this mechanism, and I always set up follow-up care to assess whether the original approach was correct or not. I have been lucky through the years in that I have had a little voice in my head which has somehow alerted me to those cases for which remote diagnosis would not be appropriate. Unfortunately, I don’t know how to transfer my little voice to anyone else, much less everyone who may benefit from it. That is why we need formalized telehealth regulations in place to protect the public.
Support Staff Could Eventually Triage Through Telehealth
Ideally, staff will eventually be able to perform the same triage functions they do in the office-based system. This will require more training, and probably more robust standard operating procedures (SOPs) because the ability to gather information is diminished (like non-verbal cues and repeated feedback loops that are a part of every face-to-face encounter we have).
So, if they are trained, and adequate protections are in place, through regulations, practice guidelines, and practice level SOPs to protect patients from inappropriate utilization, staff could be a critical and valuable part of telehealth-based care.
Telehealth Is Exciting, As Long as Profits Aren’t Put Before Patients
I, and others who discuss the need for patient protections, are not negative about telehealth.We just want to make sure we are not putting convenience, and/or profits, ahead of best practices for quality outcomes.
A colleague once paraphrased a long conversation between the two of us with a poignant analogy. After discussing the topic of telehealth for a few hours, he said to me, “So, for you, it’s like guns. The technology isn’t good or bad. It’s how you use it that is good or bad.” I am not sure that is the best analogy, but it works to illustrate the point that inappropriate use of telemedicine– the attempt to replace coordinated comprehensive care models with fragmented care and screening-only strategies–can have devastating unintended consequences.
At the same time, the appropriate and judicious use of telemedicine can improve care, access and efficiency, reducing costs for patients, providers and payers. My efforts are to ensure we use this technology in the appropriate manner and limit the inappropriate use and the damage that can cause.